Reddness to coccyx
Hello, I need help in writing a query. Redness to coccyx is documented by nursing in skin assessment since admission (7 days so far). Stage I pressure ulcer would change the SOI/ROM of this case from 2/2 to 3/3. I need help in formulating a query for this. Thanks in advance for you help.
Dawn, RN, CCDS
Dawn, RN, CCDS
Comments
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:10 AM
To: Bovard, Juli
Subject: [cdi_talk] Reddness to coccyx
Hello, I need help in writing a query. Redness to coccyx is documented by nursing in skin assessment since admission (7 days so far). Stage I pressure ulcer would change the SOI/ROM of this case from 2/2 to 3/3. I need help in formulating a query for this. Thanks in advance for you help.
Dawn, RN, CCDS
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
----------------------------------------------------------------------
Regional Health is an integrated health care system with the purpose of helping patients and communities live well.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 11:16 AM
Subject: RE: [cdi_talk] Reddness to coccyx
Has WCT done an evaluation or assessment on this pt? Nursing should put in as "assessment" for them so they can substantiate further querying and use of resources. Nursing can do that here without a provider order...
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:10 AM
To: Bovard, Juli
Subject: [cdi_talk] Reddness to coccyx
Hello, I need help in writing a query. Redness to coccyx is documented by nursing in skin assessment since admission (7 days so far). Stage I pressure ulcer would change the SOI/ROM of this case from 2/2 to 3/3. I need help in formulating a query for this. Thanks in advance for you help.
Dawn, RN, CCDS
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
----------------------------------------------------------------------
Regional Health is an integrated health care system with the purpose of helping patients and communities live well.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
This message and attachment(s), if any, is intended for the sole use of the individual and/or entity
of which it is addressed, and may contain information that is privileged,confidential and prohibited
from disclosure under applicable law. If you are not the addressee, or authorized to receive this on
behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute
to anyone this message or any part thereof. If you have received this in error, please immediately advise
the sender by e-mail and delete this information and all attachments from your computer and network.
Thank you.
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:18 AM
To: Bovard, Juli
Subject: RE: [cdi_talk] Reddness to coccyx
Nope
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 11:16 AM
Subject: RE: [cdi_talk] Reddness to coccyx
Has WCT done an evaluation or assessment on this pt? Nursing should put in as "assessment" for them so they can substantiate further querying and use of resources. Nursing can do that here without a provider order...
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:10 AM
To: Bovard, Juli
Subject: [cdi_talk] Reddness to coccyx
Hello, I need help in writing a query. Redness to coccyx is documented by nursing in skin assessment since admission (7 days so far). Stage I pressure ulcer would change the SOI/ROM of this case from 2/2 to 3/3. I need help in formulating a query for this. Thanks in advance for you help.
Dawn, RN, CCDS
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
----------------------------------------------------------------------
Regional Health is an integrated health care system with the purpose of helping patients and communities live well.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
This message and attachment(s), if any, is intended for the sole use of the individual and/or entity of which it is addressed, and may contain information that is privileged,confidential and prohibited from disclosure under applicable law. If you are not the addressee, or authorized to receive this on behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone this message or any part thereof. If you have received this in error, please immediately advise the sender by e-mail and delete this information and all attachments from your computer and network.
Thank you.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com
If you would like to be removed from CDI Talk, please send a blank email to
leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:22 AM
To: Bovard, Juli
Subject: RE: [cdi_talk] Reddness to coccyx
Can you call up to the floor and ask the nursing staff to put in assess (surprised it wasn’t auto generated already for them to see) for WCT? That way you could how WBC stages it for supporting documentation and resources; and from there ask the provider to "provide a diagnosis related to resources used and treatment provided" .... unless the pt is already discharged?
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:18 AM
To: Bovard, Juli
Subject: RE: [cdi_talk] Reddness to coccyx
Nope
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 11:16 AM
Subject: RE: [cdi_talk] Reddness to coccyx
Has WCT done an evaluation or assessment on this pt? Nursing should put in as "assessment" for them so they can substantiate further querying and use of resources. Nursing can do that here without a provider order...
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:10 AM
To: Bovard, Juli
Subject: [cdi_talk] Reddness to coccyx
Hello, I need help in writing a query. Redness to coccyx is documented by nursing in skin assessment since admission (7 days so far). Stage I pressure ulcer would change the SOI/ROM of this case from 2/2 to 3/3. I need help in formulating a query for this. Thanks in advance for you help.
Dawn, RN, CCDS
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
----------------------------------------------------------------------
Regional Health is an integrated health care system with the purpose of helping patients and communities live well.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
This message and attachment(s), if any, is intended for the sole use of the individual and/or entity of which it is addressed, and may contain information that is privileged,confidential and prohibited from disclosure under applicable law. If you are not the addressee, or authorized to receive this on behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone this message or any part thereof. If you have received this in error, please immediately advise the sender by e-mail and delete this information and all attachments from your computer and network.
Thank you.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 9:22 AM
To: Evans, Paul
Subject: RE: [cdi_talk] Reddness to coccyx
Can you call up to the floor and ask the nursing staff to put in assess (surprised it wasn’t auto generated already for them to see) for WCT? That way you could how WBC stages it for supporting documentation and resources; and from there ask the provider to "provide a diagnosis related to resources used and treatment provided" .... unless the pt is already discharged?
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:18 AM
To: Bovard, Juli
Subject: RE: [cdi_talk] Reddness to coccyx
Nope
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 11:16 AM
Subject: RE: [cdi_talk] Reddness to coccyx
Has WCT done an evaluation or assessment on this pt? Nursing should put in as "assessment" for them so they can substantiate further querying and use of resources. Nursing can do that here without a provider order...
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:10 AM
To: Bovard, Juli
Subject: [cdi_talk] Reddness to coccyx
Hello, I need help in writing a query. Redness to coccyx is documented by nursing in skin assessment since admission (7 days so far). Stage I pressure ulcer would change the SOI/ROM of this case from 2/2 to 3/3. I need help in formulating a query for this. Thanks in advance for you help.
Dawn, RN, CCDS
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
----------------------------------------------------------------------
Regional Health is an integrated health care system with the purpose of helping patients and communities live well.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
This message and attachment(s), if any, is intended for the sole use of the individual and/or entity of which it is addressed, and may contain information that is privileged,confidential and prohibited from disclosure under applicable law. If you are not the addressee, or authorized to receive this on behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone this message or any part thereof. If you have received this in error, please immediately advise the sender by e-mail and delete this information and all attachments from your computer and network.
Thank you.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: evanspx@sutterhealth.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940161.4b24e9352adc7dfa247d8332246d4e2a@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:43 AM
To: Bovard, Juli
Subject: RE: [cdi_talk] Reddness to coccyx
Yes..if WC RN can stage, then a CDI can ask the MD to 'review the WC notes and render a diagnosis based on the RN Assessment'.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044 San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 9:22 AM
To: Evans, Paul
Subject: RE: [cdi_talk] Reddness to coccyx
Can you call up to the floor and ask the nursing staff to put in assess (surprised it wasn’t auto generated already for them to see) for WCT? That way you could how WBC stages it for supporting documentation and resources; and from there ask the provider to "provide a diagnosis related to resources used and treatment provided" .... unless the pt is already discharged?
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:18 AM
To: Bovard, Juli
Subject: RE: [cdi_talk] Reddness to coccyx
Nope
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 11:16 AM
Subject: RE: [cdi_talk] Reddness to coccyx
Has WCT done an evaluation or assessment on this pt? Nursing should put in as "assessment" for them so they can substantiate further querying and use of resources. Nursing can do that here without a provider order...
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:10 AM
To: Bovard, Juli
Subject: [cdi_talk] Reddness to coccyx
Hello, I need help in writing a query. Redness to coccyx is documented by nursing in skin assessment since admission (7 days so far). Stage I pressure ulcer would change the SOI/ROM of this case from 2/2 to 3/3. I need help in formulating a query for this. Thanks in advance for you help.
Dawn, RN, CCDS
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
----------------------------------------------------------------------
Regional Health is an integrated health care system with the purpose of helping patients and communities live well.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
This message and attachment(s), if any, is intended for the sole use of the individual and/or entity of which it is addressed, and may contain information that is privileged,confidential and prohibited from disclosure under applicable law. If you are not the addressee, or authorized to receive this on behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone this message or any part thereof. If you have received this in error, please immediately advise the sender by e-mail and delete this information and all attachments from your computer and network.
Thank you.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: evanspx@sutterhealth.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940161.4b24e9352adc7dfa247d8332246d4e2a@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 11:44 AM
Subject: RE: [cdi_talk] Reddness to coccyx
RIGHT PAUL! EXACTLY
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:43 AM
To: Bovard, Juli
Subject: RE: [cdi_talk] Reddness to coccyx
Yes..if WC RN can stage, then a CDI can ask the MD to 'review the WC notes and render a diagnosis based on the RN Assessment'.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044 San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 9:22 AM
To: Evans, Paul
Subject: RE: [cdi_talk] Reddness to coccyx
Can you call up to the floor and ask the nursing staff to put in assess (surprised it wasn’t auto generated already for them to see) for WCT? That way you could how WBC stages it for supporting documentation and resources; and from there ask the provider to "provide a diagnosis related to resources used and treatment provided" .... unless the pt is already discharged?
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:18 AM
To: Bovard, Juli
Subject: RE: [cdi_talk] Reddness to coccyx
Nope
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 11:16 AM
Subject: RE: [cdi_talk] Reddness to coccyx
Has WCT done an evaluation or assessment on this pt? Nursing should put in as "assessment" for them so they can substantiate further querying and use of resources. Nursing can do that here without a provider order...
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:10 AM
To: Bovard, Juli
Subject: [cdi_talk] Reddness to coccyx
Hello, I need help in writing a query. Redness to coccyx is documented by nursing in skin assessment since admission (7 days so far). Stage I pressure ulcer would change the SOI/ROM of this case from 2/2 to 3/3. I need help in formulating a query for this. Thanks in advance for you help.
Dawn, RN, CCDS
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
----------------------------------------------------------------------
Regional Health is an integrated health care system with the purpose of helping patients and communities live well.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
This message and attachment(s), if any, is intended for the sole use of the individual and/or entity of which it is addressed, and may contain information that is privileged,confidential and prohibited from disclosure under applicable law. If you are not the addressee, or authorized to receive this on behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone this message or any part thereof. If you have received this in error, please immediately advise the sender by e-mail and delete this information and all attachments from your computer and network.
Thank you.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: evanspx@sutterhealth.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940161.4b24e9352adc7dfa247d8332246d4e2a@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
This message and attachment(s), if any, is intended for the sole use of the individual and/or entity
of which it is addressed, and may contain information that is privileged,confidential and prohibited
from disclosure under applicable law. If you are not the addressee, or authorized to receive this on
behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute
to anyone this message or any part thereof. If you have received this in error, please immediately advise
the sender by e-mail and delete this information and all attachments from your computer and network.
Thank you.
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 12:50 PM
To: Simone, Sarah
Subject: RE: [cdi_talk] Reddness to coccyx
Yes I know but in the meantime I want to place a query. All I am asking is how would you word it without being leading
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 11:44 AM
Subject: RE: [cdi_talk] Reddness to coccyx
RIGHT PAUL! EXACTLY
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:43 AM
To: Bovard, Juli
Subject: RE: [cdi_talk] Reddness to coccyx
Yes..if WC RN can stage, then a CDI can ask the MD to 'review the WC notes and render a diagnosis based on the RN Assessment'.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044 San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 9:22 AM
To: Evans, Paul
Subject: RE: [cdi_talk] Reddness to coccyx
Can you call up to the floor and ask the nursing staff to put in assess (surprised it wasn’t auto generated already for them to see) for WCT? That way you could how WBC stages it for supporting documentation and resources; and from there ask the provider to "provide a diagnosis related to resources used and treatment provided" .... unless the pt is already discharged?
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:18 AM
To: Bovard, Juli
Subject: RE: [cdi_talk] Reddness to coccyx
Nope
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 11:16 AM
Subject: RE: [cdi_talk] Reddness to coccyx
Has WCT done an evaluation or assessment on this pt? Nursing should put in as "assessment" for them so they can substantiate further querying and use of resources. Nursing can do that here without a provider order...
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 10:10 AM
To: Bovard, Juli
Subject: [cdi_talk] Reddness to coccyx
Hello, I need help in writing a query. Redness to coccyx is documented by nursing in skin assessment since admission (7 days so far). Stage I pressure ulcer would change the SOI/ROM of this case from 2/2 to 3/3. I need help in formulating a query for this. Thanks in advance for you help.
Dawn, RN, CCDS
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
----------------------------------------------------------------------
Regional Health is an integrated health care system with the purpose of helping patients and communities live well.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
This message and attachment(s), if any, is intended for the sole use of the individual and/or entity of which it is addressed, and may contain information that is privileged,confidential and prohibited from disclosure under applicable law. If you are not the addressee, or authorized to receive this on behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone this message or any part thereof. If you have received this in error, please immediately advise the sender by e-mail and delete this information and all attachments from your computer and network.
Thank you.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: evanspx@sutterhealth.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940161.4b24e9352adc7dfa247d8332246d4e2a@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12940160.55ea2c13b419eb7deb7e5125c36e4234@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
This message and attachment(s), if any, is intended for the sole use of the individual and/or entity of which it is addressed, and may contain information that is privileged,confidential and prohibited from disclosure under applicable law. If you are not the addressee, or authorized to receive this on behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone this message or any part thereof. If you have received this in error, please immediately advise the sender by e-mail and delete this information and all attachments from your computer and network.
Thank you.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: SThomas7@nwhc.net
If you would like to be removed from CDI Talk, please send a blank email to
leave-cdi_talk-20311109.45b6b16fa7892353c2765c6969dcc087@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
Note:
This message is for the named person's use only. It may contain confidential, proprietary or legally privileged information. No confidentiality or privilege is waived or lost by any mistransmission. If you receive this message in error, please immediately delete it and all copies of it from your system, destroy any hard copies of it and notify the sender. You must not, directly or indirectly, use, disclose, distribute, print, or copy any part of this message if you are not the intended recipient. This organization and any of its subsidiaries each reserve the right to monitor all e-mail communications through its networks.
Any views expressed in this message are those of the individual sender, except where the message states otherwise and the sender is authorized to state them to be the views of any such entity.
Content-Type: text/plain;
charset=us-ascii
Content-Transfer-Encoding: 7bit
Risk factor:ie immobility,dependent for care
Clinical indicator- RN admit assessment indicated red sacral area
Treatment- turn or q 2 hours,ion w meals with assist
Please clarify if above is consistent with:
*Stage 1 pressure ulcer -post
*Stage 1 pressure ulcer developed during stay
*No evidence of pressure ulcer
*Other
*Unable to determine
Sent from my iPhone
> On Jun 17, 2015, at 10:05 AM, CDI Talk wrote:
>
> This message has no content.
--Apple-Mail-5F883BDC-74FD-42A5-B3A1-2B2CAA708A8F
Content-Type: text/html;
charset=utf-8
Content-Transfer-Encoding: 7bit
Risk factor:ie immobility,dependent for careClinical indicator- RN admit assessment indicated red sacral areaTreatment- turn or q 2 hours,ion w meals with assist
Please clarify if above is consistent with:*Stage 1 pressure ulcer -post*Stage 1 pressure ulcer developed during stay*No evidence of pressure ulcer*Other*Unable to determine
Sent from my iPhone
On Jun 17, 2015, at 10:05 AM, CDI Talk <cdi_talk@hcprotalk.com> wrote: --Apple-Mail-5F883BDC-74FD-42A5-B3A1-2B2CAA708A8F--
[https://encrypted-tbn2.gstatic.com/images?q=tbn:ANd9GcRU-EgfxDFa9fzS--pfBkaCV5MlVEkmeOy8e4W_BHciawQXHPXw]
Dawn M. Vitalone, RN, CCDS
Clinical Documentation Improvement Specialist
Community Hospital
219-513-2611
dvitalone@comhs.org
[CCDS_pin_1inch]
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 12:13 PM
To: Dawn Vitalone
Subject: Re: [cdi_talk] Reddness to coccyx
Risk factor:ie immobility,dependent for care
Clinical indicator- RN admit assessment indicated red sacral area
Treatment- turn or q 2 hours,ion w meals with assist
Please clarify if above is consistent with:
*Stage 1 pressure ulcer -post
*Stage 1 pressure ulcer developed during stay
*No evidence of pressure ulcer
*Other
*Unable to determine
Sent from my iPhone
On Jun 17, 2015, at 10:05 AM, CDI Talk wrote:
This message has no content.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org
If you would like to be removed from CDI Talk, please send a blank email to
leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
This message and attachment(s), if any, is intended for the sole use of the individual and/or entity
of which it is addressed, and may contain information that is privileged,confidential and prohibited
from disclosure under applicable law. If you are not the addressee, or authorized to receive this on
behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute
to anyone this message or any part thereof. If you have received this in error, please immediately advise
the sender by e-mail and delete this information and all attachments from your computer and network.
Thank you.
I'll locate that position paper and send to you.
Ann
Sent from my iPhone
> On Jun 17, 2015, at 10:14 AM, CDI Talk wrote:
>
> This isn’t considered leading since ulcer is not documented
>
>
> Dawn M. Vitalone, RN, CCDS
> Clinical Documentation Improvement Specialist
> Community Hospital
> 219-513-2611
> dvitalone@comhs.org
>
>
> From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
> Sent: Wednesday, June 17, 2015 12:13 PM
> To: Dawn Vitalone
> Subject: Re: [cdi_talk] Reddness to coccyx
>
> Risk factor:ie immobility,dependent for care
> Clinical indicator- RN admit assessment indicated red sacral area
> Treatment- turn or q 2 hours,ion w meals with assist
>
> Please clarify if above is consistent with:
> *Stage 1 pressure ulcer -post
> *Stage 1 pressure ulcer developed during stay
> *No evidence of pressure ulcer
> *Other
> *Unable to determine
>
> Sent from my iPhone
>
> On Jun 17, 2015, at 10:05 AM, CDI Talk wrote:
>
> This message has no content.
>
> ---
> CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
>
> You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org
> If you would like to be removed from CDI Talk, please send a blank email to
> leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
> ---
> Copyright 2013
> HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
> This message and attachment(s), if any, is intended for the sole use of the individual and/or entity of which it is addressed, and may contain information that is privileged,confidential and prohibited from disclosure under applicable law. If you are not the addressee, or authorized to receive this on behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone this message or any part thereof. If you have received this in error, please immediately advise the sender by e-mail and delete this information and all attachments from your computer and network. Thank you.
>
> ---
> CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
>
> You are receiving this message as a member of CDI Talk as: annnd2009@gmail.com
> If you would like to be removed from CDI Talk, please send a blank email to
> leave-cdi_talk-13089320.38a6920d4dbebb3c0272be2f9e77119e@hcprotalk.com
> ---
> Copyright 2013
> HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
--Apple-Mail-5209D159-9194-49C8-85A8-59AA5E202980
Content-Type: multipart/related;
type="text/html";
boundary=Apple-Mail-BE0DE417-26C5-4405-B38B-2277C99C62D9
Content-Transfer-Encoding: 7bit
--Apple-Mail-BE0DE417-26C5-4405-B38B-2277C99C62D9
Content-Type: text/html;
charset=utf-8
Content-Transfer-Encoding: quoted-printable
You will always have some debate on this subject,but when ahima stated in their position paper what leading. I don't feel this is leading. What other reasonable answer would you expect from a reddened area on the sacrum? If you can think of ANY REASONABLE choice. It seems that may be the only reasonable choice other than. There was no pressure ulcer ever which is provided.
I'll locate that position paper and send to you.
Ann
Sent from my iPhone
On Jun 17, 2015, at 10:14 AM, CDI Talk <cdi_talk@hcprotalk.com> wrote: --Apple-Mail-BE0DE417-26C5-4405-B38B-2277C99C62D9
Content-Type: image/jpeg;
name=image002.jpg;
x-apple-part-url="image002.jpg@01D0A8F7.39059500"
Content-Disposition: inline;
filename=image002.jpg
Content-Transfer-Encoding: base64
Content-Id:
/9j/4AAQSkZJRgABAQEAkACQAAD/2wBDAAoHBwkHBgoJCAkLCwoMDxkQDw4ODx4WFxIZJCAmJSMg
IyIoLTkwKCo2KyIjMkQyNjs9QEBAJjBGS0U+Sjk/QD3/2wBDAQsLCw8NDx0QEB09KSMpPT09PT09
PT09PT09PT09PT09PT09PT09PT09PT09PT09PT09PT09PT09PT09PT09PT3/wAARCABFAEUDASIA
AhEBAxEB/8QAHwAAAQUBAQEBAQEAAAAAAAAAAAECAwQFBgcICQoL/8QAtRAAAgEDAwIEAwUFBAQA
AAF9AQIDAAQRBRIhMUEGE1FhByJxFDKBkaEII0KxwRVS0fAkM2JyggkKFhcYGRolJicoKSo0NTY3
ODk6Q0RFRkdISUpTVFVWV1hZWmNkZWZnaGlqc3R1dnd4eXqDhIWGh4iJipKTlJWWl5iZmqKjpKWm
p6ipqrKztLW2t7i5usLDxMXGx8jJytLT1NXW19jZ2uHi4+Tl5ufo6erx8vP09fb3+Pn6/8QAHwEA
AwEBAQEBAQEBAQAAAAAAAAECAwQFBgcICQoL/8QAtREAAgECBAQDBAcFBAQAAQJ3AAECAxEEBSEx
BhJBUQdhcRMiMoEIFEKRobHBCSMzUvAVYnLRChYkNOEl8RcYGRomJygpKjU2Nzg5OkNERUZHSElK
U1RVVldYWVpjZGVmZ2hpanN0dXZ3eHl6goOEhYaHiImKkpOUlZaXmJmaoqOkpaanqKmqsrO0tba3
uLm6wsPExcbHyMnK0tPU1dbX2Nna4uPk5ebn6Onq8vP09fb3+Pn6/9oADAMBAAIRAxEAPwD2HIUg
Y4NQXl7BYQtJcSBEHc064u47W1a4lIEajNeT6tql54y1ZrWCUwWitgyf3a2o0XN3exm25NQpo1tc
+JLvcG10iFnbO3cOSTWNNH4o1CFrm9kaGIdFfr9KzrbVbfSwbW1tvPvImKtgfeOeGzWjbeGvE3iA
PNPczRqx3KpOBXYvc+DRGk6VCk7VNWZ95pms2Nkt2t0suWGFVuQDWhFqHibR/KeM/aIWXdtXjb9a
uv8ADDUQCy37ksPnG7gmsy70zxJ4bIdyZ4v9sbsVfPKp7vNchfU5fYsdd4e+ItvfSLb6gphn6Zbi
u4SRZUDoQwIyCK8Xt4dP8TKytOLS+X7qEYLN6Ctzwj4lvNG1D+x9YDKw4UseMVzVKKnfk0aFOEqH
vbxZ6cOnFFM3HAK4IIzRXGPm8jz34i6+/lLp1qcOzbTj3rlL6M+G7aGzsZma7uV/eLjPXvVgP/bH
jZmkBwgLhT90ml0eE6144ImUBYSAEXouK9SMVD3Y/MdCbp0JVZbs6rwZ4MjsLFby8jEtywyu7uam
8Q+Jr+BUtLOMWFyp3FpvuMo6gV2sahYgo4AGBXD6/pX22W6s79i0co3Rv6NXmVcTaa5tjXCUVJ80
tXuTWviHVb22WZzHbxvzGx/jHfFdHaznU7YLNb5jIwdw61nx6Wk9jplu+CIEGce1dAqqqgL0rni5
uq2noa1nGStynlvjbwmdKnXVdNQK0R3Kf7prL1O6/wCEl0eHUlPl3tqMvgdcda9c1S0S902aGQZD
Ka8f0APYa5f2OMwuDuB7CvXpydSDk90c9B2vS6dD07wvq6apoVvKxzIqBW+uKK4nwRq4sLO8ik7T
nbz2oqHhpPVI82pjJ05OHYwdJ3xeLptpxK2CAx4PqPatXwW6R+OLtcAb5DtqHxFaf2J4tS4dCsJk
5PqKi1KRdC8VWupWmTbT4yffvXRL3pNrqjvpv2mDt1W/yPU7zWorW5+zrHJJIOSFGcVBe6pYzRRe
bA7ytysePm/KqVmbhpm1LTo47iK5AJDNypqeW0vxeQ38cMbSFdrx/wB2vnantE3GS6nbT9k0nF6W
Hx6tbWsKMkMpLHaEI5FWB4htBBI7bkZPvIwwapXNtqN00Ext1R43yEHT8aa2l3dy891cwR7n4EXY
1DqV1dRWhpyUmld/ia1pqK3kEjeW6YX+IcGvIoLmFPHdxNIR5A3bsV3F7eS+HdFu2uH2eapEMbHk
etcX4YQJZanrVxkpsOAyDDE+lexg+f2Lm+pzwUfrLtskM8PwG6F5JHt8szHaR6UV1PgLSh/YrzTR
j98+9QR2or0PrCh7rPnMRzSqycdrm3428OrrejvsGJU+YEV5VbR6hrLnSLuYIYeUZuwHtXvRGQQe
Qa4bxd4Ka4mOo6WTFcJ8w2cc1xUKq+FnswqOhNyWsXucr4f8U3nhS6+y3yt9mLYVm6N/hXp2m+J9
O1KLfDcID6E15W/iCSNRY69p6BQcSSbeWHt6UyPQbC6uIzpGpyRxuM5bt7VrOnGXxbmjoRbvRlZd
j2b7fb4yZk+u6sTWvGumaTAzeeskg6KDXmd7oGt2ttJLJqK+Uv3MNy9Fpo+k2QS71q9LsQD5QGc1
CoU1uw+rVl8ckkS3M2peOdRWdgU0+Nvmcnjj0FLfyzazcwaHprK1mjjeYxgGpm1K91pjp3h21+zW
bHlwOa7vwl4Qg0K2Eki7rhuST2rSU4whzVNuiJnUUF7Gjv1Zt6bYRWGnwW4GAigYoq6VDcnmivPc
pN3JVKNthB92lwOKKKXQtPQydV8O6fqyn7TApPqBXCav4EsrUM1vPNGAeApoortwsm5JM8/EydJO
UNGYp8PLK6xyXdwyYxgtXSaN4B024xPcPJKV4Ct0ooruxSUYXRy08TWlJJyZ3GnaXaadGFtYVTHo
KvjqaKK8Wbcp6nr0kuUjZiDRRRQYtu5//9k
--Apple-Mail-BE0DE417-26C5-4405-B38B-2277C99C62D9--
--Apple-Mail-5209D159-9194-49C8-85A8-59AA5E202980--
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDocName=bok1_050018
It can be frustrating because the examples are SOOO obvious. And I think coding is USUALLY more comfortable with open- ended questions but, in a clinical person’s experience they may find their choices the reasonable choices.
Different programs set up their queries differently based on their comfort level but if you give other and unable to determine they are NOT GIVEN ONLY ONE CHOICE…
Good luck!
Sent from my iPhone
> On Jun 17, 2015, at 10:14 AM, CDI Talk wrote:
>
> This isn’t considered leading since ulcer is not documented
>
>
> Dawn M. Vitalone, RN, CCDS
> Clinical Documentation Improvement Specialist
> Community Hospital
> 219-513-2611
> dvitalone@comhs.org
>
>
> From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
> Sent: Wednesday, June 17, 2015 12:13 PM
> To: Dawn Vitalone
> Subject: Re: [cdi_talk] Reddness to coccyx
>
> Risk factor:ie immobility,dependent for care
> Clinical indicator- RN admit assessment indicated red sacral area
> Treatment- turn or q 2 hours,ion w meals with assist
>
> Please clarify if above is consistent with:
> *Stage 1 pressure ulcer -post
> *Stage 1 pressure ulcer developed during stay
> *No evidence of pressure ulcer
> *Other
> *Unable to determine
>
> Sent from my iPhone
>
> On Jun 17, 2015, at 10:05 AM, CDI Talk wrote:
>
> This message has no content.
>
> ---
> CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
>
> You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org
> If you would like to be removed from CDI Talk, please send a blank email to
> leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
> ---
> Copyright 2013
> HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
> This message and attachment(s), if any, is intended for the sole use of the individual and/or entity of which it is addressed, and may contain information that is privileged,confidential and prohibited from disclosure under applicable law. If you are not the addressee, or authorized to receive this on behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone this message or any part thereof. If you have received this in error, please immediately advise the sender by e-mail and delete this information and all attachments from your computer and network. Thank you.
>
> ---
> CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
>
> You are receiving this message as a member of CDI Talk as: annnd2009@gmail.com
> If you would like to be removed from CDI Talk, please send a blank email to
> leave-cdi_talk-13089320.38a6920d4dbebb3c0272be2f9e77119e@hcprotalk.com
> ---
> Copyright 2013
> HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
--Apple-Mail-CB2D22B8-D900-4F98-A584-8ECFEF940EF3
Content-Type: multipart/related;
type="text/html";
boundary=Apple-Mail-5F6DA779-4458-4946-B79A-C7D9D0BFB08C
Content-Transfer-Encoding: 7bit
--Apple-Mail-5F6DA779-4458-4946-B79A-C7D9D0BFB08C
Content-Type: text/html;
charset=utf-8
Content-Transfer-Encoding: quoted-printable
Excerpt--A query should include the clinical indicators, as discussed above, and should not indicate the impact on reimbursement. A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure. **********The justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the query format.
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDocName=bok1_050018
It can be frustrating because the examples are SOOO obvious. And I think coding is USUALLY more comfortable with open- ended questions but, in a clinical person’s experience they may find their choices the reasonable choices.
Different programs set up their queries differently based on their comfort level but if you give other and unable to determine they are NOT GIVEN ONLY ONE CHOICE…
Good luck!
Sent from my iPhoneOn Jun 17, 2015, at 10:14 AM, CDI Talk <cdi_talk@hcprotalk.com> wrote: --Apple-Mail-5F6DA779-4458-4946-B79A-C7D9D0BFB08C
Content-Type: image/jpeg;
name=image001.jpg;
x-apple-part-url="image001.jpg@01D0A8F7.39059500"
Content-Disposition: inline;
filename=image001.jpg
Content-Transfer-Encoding: base64
Content-Id: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--Apple-Mail-5F6DA779-4458-4946-B79A-C7D9D0BFB08C--
--Apple-Mail-CB2D22B8-D900-4F98-A584-8ECFEF940EF3--
In addition, my concerns would include whether a doctor would order a wound care consult for a suspected stage I (times may have changed since I was a bedside nurse), and what the appropriate CDI intervention should be for facilities that do not have a wound care team.
Renee
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation
Tanner Health System
Dawn
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 1:21 PM
Subject: Re:[cdi_talk] Reddness to coccyx
As Sarah noted, there can be many reasons for a reddened sacrum other than a stage I pressure ulcer. Pointing a physician toward a singular diagnosis to the exclusion of other options when there is no documentation of anything other than redness feels very leading to me. For me, adding 'other' and 'unable to determine' does not change that. What is the nursing protocol for documentation of skin issues? Some facilities do not allow their nurses to document or stage ulcers, but only to document objective findings. In that case I would definitely want the doctor to flip the patient over themselves and take a peek at their backside. I think I would create an open-ended query that asks the physician if there is an associated diagnosis to account for the findings.
In addition, my concerns would include whether a doctor would order a wound care consult for a suspected stage I (times may have changed since I was a bedside nurse), and what the appropriate CDI intervention should be for facilities that do not have a wound care team.
Renee
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP Director, Clinical Documentation Tanner Health System
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
This message and attachment(s), if any, is intended for the sole use of the individual and/or entity
of which it is addressed, and may contain information that is privileged,confidential and prohibited
from disclosure under applicable law. If you are not the addressee, or authorized to receive this on
behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute
to anyone this message or any part thereof. If you have received this in error, please immediately advise
the sender by e-mail and delete this information and all attachments from your computer and network.
Thank you.
Similar to nutritional status, I feel this is a very nuanced area. I find that often the physicians defer to expertise of the WC RN for related conditions/diagnoses.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 11:24 AM
To: Evans, Paul
Subject: RE: Re:[cdi_talk] Reddness to coccyx
Thank you Renee and everyone else. This is something that is going to get addressed now that we have access to the APR-DRG grouper.
Dawn
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, June 17, 2015 1:21 PM
Subject: Re:[cdi_talk] Reddness to coccyx
As Sarah noted, there can be many reasons for a reddened sacrum other than a stage I pressure ulcer. Pointing a physician toward a singular diagnosis to the exclusion of other options when there is no documentation of anything other than redness feels very leading to me. For me, adding 'other' and 'unable to determine' does not change that. What is the nursing protocol for documentation of skin issues? Some facilities do not allow their nurses to document or stage ulcers, but only to document objective findings. In that case I would definitely want the doctor to flip the patient over themselves and take a peek at their backside. I think I would create an open-ended query that asks the physician if there is an associated diagnosis to account for the findings.
In addition, my concerns would include whether a doctor would order a wound care consult for a suspected stage I (times may have changed since I was a bedside nurse), and what the appropriate CDI intervention should be for facilities that do not have a wound care team.
Renee
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP Director, Clinical Documentation Tanner Health System
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: dvitalone@comhs.org If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12121342.2ffcc42f203494f36544e53ea82f91d7@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
This message and attachment(s), if any, is intended for the sole use of the individual and/or entity of which it is addressed, and may contain information that is privileged,confidential and prohibited from disclosure under applicable law. If you are not the addressee, or authorized to receive this on behalf of the addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone this message or any part thereof. If you have received this in error, please immediately advise the sender by e-mail and delete this information and all attachments from your computer and network.
Thank you.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: evanspx@sutterhealth.org
If you would like to be removed from CDI Talk, please send a blank email to
leave-cdi_talk-12940161.4b24e9352adc7dfa247d8332246d4e2a@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
In the end you have to feel comfortable defending it. Unless something known and not listed. I'd feel very comfortable defending... Ask yourself what do you as the surveyor of the record suspect to be a reasonable cause?